A SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE VOL 61, NO 4 • APRIL 2012 Men, WoMen, and MIgraIne: The role of Sex, horMoneS, obesity, and PTSd Commentary Pain—It’s not that simple The benefits of interdisciplinary pain management A SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE For more information, visit us at chronicpainperspectives.com April 2012 CONTENTS commentary S5 | Pain—It’s not that simple Robert Bonakdar, MD FEATURE ARTIcLeS S7 | Men, women, and migraine: The role of sex, hormones, obesity, and PTSD B. Lee Peterlin, DO Anne H. Calhoun, MD Fred Balzac S12 | The benefits of S7 interdisciplinary pain management Carl Noe, MD Charles F. Williams Special thanks to our editorial consultant Kristen Georgi for her research, writing, and editing efforts. Cover illustration: Stephanie Dalton Cowan cHronIc PaIn PerSPectIVeS Please snap a picture aDVISORY BoarD with your Smartphone to see our new Web site. roBERT A. BonaKDar, mD PaUL J. cHrISto, mD, mBa Board Chairman Assistant Professor, Division of Pain Medicine, Director of Pain Management, Director, Multidisciplinary Pain Scripps Center for Integrative Fellowship Program (2003-2011), Medicine; Assistant Clinical Johns Hopkins For information about sponsorship opportunities, Professor, Department of Family University School please contact Elaine Coutsouridis at and Preventative Medicine, of Medicine, Baltimore, MD [email protected] or, 973-663-1232. University of California School of Medicine, San Diego, CA For information about submitting manuscripts, please contact Editor at [email protected]. mIcHaeL r. cLarK, mD, mPH, mBa Associate Professor and Chronic Pain Perspectives™ is a supplement to Director, Chronic Pain The Journal of Family Practice™ and a registered Treatment Program, Johns trademark of Quadrant HealthCom Inc. Hopkins University School Copyright © Quadrant HealthCom Inc. 2012 of Medicine, Baltimore, MD S4 | april 2012 • VOl 61, NO 4 • SUPPLEMENT TO THE JOUrNAL OF FaMILY PRACTiCE chroniCpaiNpErSpectives.com Commentary Pain – It’s not that simple The complex problem of pain rarely has a simple solution. Here’s why. Robert Bonakdar, MD Director of Pain Management Scripps Center for Integrative Medicine San Diego, CA; Advisory Board Chairman, Chronic Pain Perspectives L. Mencken was a 20th century journal- fact that their pain is not a discrete entity. Pain ist and critic who provided us with a is a doorway into a sequela of suffering that Hnumber of great quotes. One of my needs to be appreciated and addressed if we favorites is: have any hope of helping our patients return to functionality. “There is always an easy solution to every human problem—neat, plausible, and wrong."1 Pain does not travel alone The research guides us to understand that I like this quote because it applies to many when there is pain, there are current or emerg- aspects of pain. In this and upcoming issues ing issues with mood, energy, cognition, and of Chronic Pain Perspectives, we examine why function. Although depression is found in chronic pain needs to be viewed as a complex approximately 10% to 15% of all patients seen situation that affects the mind, body, and soul in primary care, those who have chronic pain of our patients, one in which the simple, neat have been found to present with depression as solution is often not enough. Although we may much as 58% of the time,2 making it the most wish to “tackle” pain as we would an objective common psychiatric comorbity. Conversely, in a value and reduce it with a unimodal approach, large study of primary care patients with major experience and several lines of research dem- depressive disorder, chronic pain was present onstrate that we are positioning ourselves, nearly 66% of the time.3 and our patients, for disappointment. The Beyond depression, the patient with chronic problem here is not in our patients, but in the pain is more likely to have coexisting anxiety,3 chronicpainperspectives.com SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE • VOL 61, NO 4 • april 2012 | S5 panic,3 sleep dysfunction characterized by sleep this out; in a 30-year study of headache, over maintenance insomnia and fatigue,4 restless leg the course of their illness patients were found syndrome,4 and loss of gray matter density that to switch from their initial diagnosis of head- may be reversible.5,6 ache type to other headache diagnoses more This brings up the age-old intellectual ques- than 80% of the time.8 [Figure] tion, “Which came first?” What we appreciate What this creates is the awareness that we more and more—through understanding the are not really fighting a single condition, but a common pathophysiological mechanisms seen complex picture of suffering, and that we must in conditions such as migraine, depression, and take into account many layers of the patient The problem cardiovascular disease,7—is that these disor- who presents to us. In this way we can push here is not in ders are co-developing and making their way past the simple but disappointing solution to a into the chief complaint in various layers and more integrative, individualized, complex one our patients, word choices. that holds the potential for relief on multiple but in the levels. fact that their I’ll leave you with another Mencken quote pain is not Pain does not stay in the same silo that offers sage advice in this regard: a discrete As we focus more closely on pain as a foe that entity. we can subdue, we find that it exerts an influ- “The essence of science is that it is always ence on many “friends,” and that pain and its willing to abandon a given idea, however elusive friends have the ability to jump from one fundamental it may seem to be, for a bet- arena into another, sometimes making the bat- ter one.“ 9 tle feel insurmountable. Recent research points REFERENCES 1. Mencken HL. “The Divine Afflatus,” A Mencken FIGURE: Combinations of headache subtypes across 30 years Chrestomathy. Chapter 25, p. 443. 1949. among participants who met criteria for migraine or tension-type 2. Castro M, Kraychete D, Daltro C, et al. Comorbid anxi- headache (n=346) ety and depression disorders in patients with chronic pain. Arq Neuropsiquiatr. 2009;67(4):982-985. 3. Arnow BA, Hunkeler EN, Blasey CM, et al. Comorbid depression, chronic pain, and disability in primary care. Migrane Tension-type Psychosom Med. 2006;68:262-268. without aura headache 4. Alattar M, Harrington JJ, Mitchell CM, et al. Sleep problems in primary care: A North Carolina Family Practice Research Network (NC_FP_RN) study. J Am Bd Fam Med. 2007;20(4)365-374. 5. Apkarian AV, Sosa Y, Sonty S, et al. Chronic back pain is associated with decreased prefrontal and thalamic 31.5% gray matter density. J Neurosci. 2004;24(46):10410- 24.6% 10415. 36.4% 6. Seminowicz DA, Wideman TH, Naso L, et al. Effective 2.0% treatment of chronic low back pain in humans reverses 4.9% abnormal brain anatomy and function. J Neurosci. 2011;31(20)7540-7550. 0.6% 7. Park KIE, Pepine CJ. Pathophysiologic mechanisms linking impaired cardiovascular health and neuro- logic function: the year in review. Clev Clin J Med. Migrane 2010;77(suppl 3):S40-S45. with aura 8. Merikangas KR, Cui L, Kalydjian, et al. Magnitude, impact, and stability of primary headache sub- types: 30 year prospective Swiss cohort study. BMJ. Source: Adapted from Merikangas KR, et al. Magnitude, impact, and stability of primary headache 2011;343:d5706. subtypes: 30 year prospective Swiss cohort study. BMJ. 2011;343:d5706 9. Mencken HL. Minority Report, no 232. 1956. S6 | april 2012 • VOL 61, NO 4 • SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE chronicpainperspectives.com Feature article Men, women, and migraine: the role of sex, hormones, obesity, and PtSD Links between migraine and certain comorbidities suggest new approaches to patient education, screening, and treatment. B. Lee Peterlin, DO Assistant Professor of Neurology Director, JHU Headache Research, Johns Hopkins University Baltimore, MD Anne H. Calhoun, MD Partner, Co-Founder, Carolina Headache Institute Adjunct Professor, Department of Anesthesiology; Adjunct Professor, Department of Psychiatry, University of North Carolina Chapel Hill, NC Fred Balzac Medical writer Jay, NY igraine is a common neurologic dis- much higher in females from age 12 across the order that occurs in approximately lifespan.1 In comparison, for tension-type head- 3 times as many females as males in ache the female to male ratio of occurrence is M 2 the United States. Among 30,000 respondents, 5:4, occurring only slightly more in females. the American Migraine Study II found that the The reasons for this disparity in migraine preva- prevalence of migraine was 18.2% among lence are not well understood. The dispropor- females and 6.5% among males, and was tionate number of women of reproductive age Disclosures B. Lee Peterlin, DO, has received grant/research support from GlaxoSmithKline, has served as a consultant to Nautilus, and has served on the speaker’s bureau of Zogenix. She holds a provisional patent for use of adiponectin-modulating drugs for migraine. Anne H. Calhoun, MD, has no conflicts of interest to report. Fred Balzac has no conflicts of interest to report. chronicpainperspectives.com SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE • VOL 61, NO 4 • april 2012 | S7 with migraine suggests that hormonal factors Hormonal factors: may play a role, but the complex pathophysiol- Menstrual-related migraine ogy of migraine indicates additional factors are With migraine disproportionately affecting involved.3 women of reproductive age, as many as 70% Recent research on menstrual-related of female migraineurs are aware of a menstrual migraine and two significant comorbidities of association with their headaches.15 A menstrual migraine—obesity and posttraumatic stress migraine is defined as migraine without aura disorder (PTSD)—shed new light on the dif- that occurs during the 5-day window that begins ferences in how men and women present with 2 days before the onset of bleeding and extends As many and experience this often disabling disorder.